As reported in The Lancet Oncology by de Boer et al, a post hoc updated survival analysis of the phase III PORTEC-3 trial has shown a significant overall survival benefit of adjuvant chemoradiotherapy vs radiotherapy alone in women with high-risk endometrial cancer. A benefit in failure-free survival was maintained.
Previously reported trial results showed a significant failure-free survival benefit but no significant overall survival benefit after a median follow-up of 60.2 months. The current report included an analysis of patterns of recurrence in the trial.
The open-label trial included 660 women from 103 sites within six clinical trial groups collaborating in the Gynecological Cancer Intergroup. Patients were randomly assigned between November 2006 and December 2013 to receive radiotherapy alone at 48.6 Gy in 1.8 Gy fractions 5 days per week (n = 330) or chemoradiotherapy with two cycles of cisplatin 50 mg/m² during radiotherapy followed by four cycles of carboplatin (area under the curve = 5) and paclitaxel 175 mg/m² (n = 330). Patients had to have International Federation of Gynecology and Obstetrics 2009 stage I endometrioid grade 3 cancer with deep myometrial invasion, lymphovascular space invasion, or both; stage II or III disease; or stage I to III disease with serous or clear cell histology. Randomization was stratified by participating center, lymphadenectomy, stage, and histological type. The coprimary endpoints were overall and failure-free survival.
Overall and Failure-Free Survival
At a median follow-up of 72.6 months, estimated 5-year overall survival adjusted for stratification factors was 81.4% in the chemoradiotherapy group vs 76.1% in the radiotherapy group (adjusted hazard ratio [HR] = 0.70, P = .034). The rates of 5-year failure-free survival were 76.5% vs 69.1% (HR = 0.70, P = .016).
In post hoc exploratory analyses, 5-year overall survival rates were 78.5% in the chemoradiotherapy group vs 68.5% in the radiotherapy group (HR = 0.63, P = .043), and 5-year failure-free survival rates were 70.9% vs 58.4% (HR = 0.61, P = .011) among women with stage III endometrial cancer. Among women with stage I or II disease, 5-year rates were 83.8% vs 82.0% (HR = 0.83, P = 0.45) for overall survival and 81.3% vs 77.3% for failure-free survival (HR = 0.86, P = .51). Among patients with serous cancers, 5-year rates were 71.4% vs 52.8% (HR = 0.48, P = .037) for overall survival and 59.7% vs 47.9% (HR = 0.42, P = .008) for failure-free survival.
Distant metastases—the most common type of recurrence—constituted the first type of recurrence in 78 patients in the chemoradiotherapy group vs 98 in the radiotherapy group (5-year probability = 21.4% vs 29.1%, HR = 0.74, P = .047). Overall, distant metastases occurred in 80 vs 99 patients (5-year probability = 22.1% vs 29.4%, P = .057). Pelvic recurrence was observed in 20 vs 31 patients (5.5% vs 8.5%, HR = 0.63, P = 0.11) and vaginal recurrence was observed in eight vs eight patients (2.1% vs 2.1%, HR = 0.99, P = 0.99. Pelvic recurrence was the first recurrence in three vs four patients, and vaginal recurrence was the first recurrence in one patient in each group.
With additional follow-up from the time of prior reports, no significant differences between groups were observed in grade ≥ 3 adverse events at 12, 36, or 60 months after randomization. At 60 months, grade 3 adverse events were reported in 8% of 201 women in the chemoradiotherapy group vs 5% of 187 women in the radiotherapy group (P = .24). One grade 4 adverse event (ileus or obstruction) was reported in the chemoradiotherapy group. The most common grade 3 adverse events were hypertension (2% vs 2%) and any pain (1% vs 2%). Grade ≥ 2 adverse events were more common in the chemoradiotherapy group, occurring in 38% of 201 women vs 23% of 187 women (P = .002); grade ≥ 2 sensory neuropathy was observed in 6% vs 0%. No treatment-related deaths were observed.
The investigators concluded, “This updated analysis shows significantly improved overall survival and failure-free survival with chemoradiotherapy vs radiotherapy alone. This treatment schedule should be discussed and recommended especially for women with stage III or serous cancers, or both, as part of shared decision-making between doctors and patients. Follow-up is ongoing to evaluate long-term survival.”
Stephanie de Boer, MD, of the Department of Radiation Oncology, Leiden University Medical Center, is the corresponding author for The Lancet Oncology article.
Disclosure: The study was funded by the Dutch Cancer Society, Cancer Research UK, National Health and Medical Research Council, Project Grant, Cancer Australia Grant, Italian Medicines Agency, and the Canadian Cancer Society Research Institute. For full disclosures of the study authors, visit thelancet.com.
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